Increasingly Frequent Angina

A 67-year-old white man presented to Hermann Hospital upon referral from an Austin, Tex, physician for evaluation of recurrent chest pain. Eighteen months before admission the patient first noted episodes of chest discomfort, which he described as a left parasternal sensation of heaviness or tightness variably associated with moderate physical exertion. The discomfort would last 3 to 4 minutes and resolved with rest. He experienced one or two episodes each month. Two months before admission, an exercise stress test was performed and demonstrated 1.0 mm of "flat STsegment depression" in leads II, III, aVF, and V4 through V6 at peak exercise (Bruce protocol; stage IV, 10 minutes). He experienced no pain during the test, and the ECG changes resolved within 30 seconds of stopping exercise. Five days before admission, the episodes of pain increased markedly in frequency, occurred several times a day, were provoked with only minimal exertion, and occurred at rest. He also noted episodes of left arm pain, with or without chest pain, which would last 30 to 60 minutes. He was pain-free on admission. He denied any associated nausea, vomiting, diaphoresis, palpitations, dyspnea, orthopnea, edema, or fatigue. He reported no other symptoms.